A shot to the head

A couple of onlinearticles have discussed whether you would be conscious of being shot in the head with the general conclusion that it is unlikely because the damage happens faster than the brain can register a conscious sensation.

While this may be true in some instances it ignores that fact that there are many ways of taking a bullet to the head.

This is studied by a field called wound ballistics and, unsurprisingly when you think about it, the wound ballistics of the head are somewhat special.

Firstly, if you get shot in the head, in this day and age, you have, on average, about a 50/50 chance of surviving. In other words, it’s important to note that not everyone dies from their injuries.

But it’s also important to note that not every bullet wound will necessarily damage brain areas essential for consciousness.

The image on the top left of this post charts the position of fatal gunshot wounds recorded in soldiers and was published in a recent study on combat fatalities.

For many reasons, including body armour and confrontation type, head wounds to soldiers are not necessary a good guide to how these will pan out in civilians, but you can see that there are many possibilities with regard to which brain areas could be affected.

In fact, you can see differences in the effect of gunshots to the head more directly from the data from Glasgow Coma Scale (GCS) ratings. A sizeable minority are conscious when they first see someone from the trauma team.

It’s also worth noting that deaths are not necessarily due to brain damage per se, blood loss is also a key factor.

An average male has about 6 litres of blood and his internal carotid artery clears about a quarter of a litre per minute at rest to supply the brain. When in a stressful situation, like, for example, being shot, that output can double.

If we need to lose about 20% of our blood to lose consciousness, our notional male could black out in just over two minutes just through having damage to his carotid. However, that’s two minutes of waiting if he’s not been knocked unconscious by the impact.

But if we’re thinking about brain damage, the extent depends on a whole range of ballistic factors – the velocity, shape, size and make-up of the bullet being key.

As it turns out, the brain needs special consideration, not least because it is encased in the skull.

One of the first things to consider is that the skull can fracture and how the fragments themselves can become missiles. In 42 cases of civilian gunshot wounds to the brain two neurosurgeons were able to find bone chips in 16 patients’ brains simply by “digital palpation” – which is a complicated medical term for sticking your fingers in and wiggling them about.

In other words, a shot to one part of the head may have knock-on effects purely due to skull shattering.

However, the skull also sets up a unique target due to its enclosed nature. If someone gets shot in the leg the pressure of the impact can be released into the surroundings. If a bullet gets into the brain the options are fewer because the pressure waves and, indeed, the brain, are largely trapped inside a solid box of bone.

If you want to get an idea of the sorts of pressures involved, just catch a video or two of bullets being fired into ballistic gel and think what would happen if the gel was trapped inside a personally important life-sustaining box.

In fact, if the shot is powerful enough, from high velocity rifles for example, there is a combination of the initial impact and an ‘explosive’ effect which can do substantial damage through forcing the brain to the side of the skull and fracturing from the inside out.

There is one rare effect, called the Krönlein shot, where a high powered shot messily opens the skull but neatly ejects the whole brain on the ground. You can find pictures on the web from pathology articles but, I warn you, they’re neither child friendly nor particularly good tea-time viewing.

Small low-velocity rounds can do quite local damage, however, and despite the tragedy of being shot, we have learnt a surprising amount from people who have survived such wounds.

As we’ve discussed previously, the use of small bore low-velocity bullets during World War I meant that more than ever before and, perhaps since, soldiers survived with small localised brain injuries.

This meant doctors could do some of the first systematic studies into how specific brain areas related to specific functions, based on tests of what brain-injured soldiers could no longer do.

But while it’s true to say that many people will lose consciousness before they even know they’ve been shot, it’s not guaranteed. Although it will mean that some people will be unfortunately aware of their death, it also means that others are able to save themselves.

You answered a question that’s been bothering me for a long time. I was on the jury of the “Uzi death trial”; the media reported later that the boy who shot himself in the head was screaming after he hit the ground. I assumed that was incorrect because how can someone scream after they were shot in the head with a machine gun? I guess the only question then is if that is an involuntary reaction.

This is excellent. Obviously everyone shot in the head does not die. An interesting point is this: Is it the location of the injury? Or is it the chemical changes that occur? Or might it be individualized depending on the fragility of each brain. I understand some areas are definitely fatal, but it the other areas that are in question.

I work for a 9-1-1 dispatch center and can honestly attest that it is quite common for people who’ve been shot in the head to survive. We’ve had several incidences in the past year where gunshot victims survived.

Good piece. I perform shooting incident analysis/reconstruction and research on the perception of pain related to gunshot wounds.

Gunshot victims to a high percentage do not feel pain from a gunshot wound; to the head or elsewhere. This appears to be associated with the lack of pain from other serious injuries like those sustained in a car crash.

There are also many cases in which the gunshot victim is conscious and talking immediately after the bullet strike — even when the injury later causes death.

That life threatening or other serious injury does not cause (immediate) pain is documented but not well understood. It may be a function of the fight-or-flight response. One of the body’s use of pain is to tell you to stop doing what you are doing; that your action is or will be causing harm.

In life-threatening situations, pain will interfere with your ability to flee or to fight. So it may be that your brain recognizes serious injuries and surpresses the pain so you can get away or defend yourself.

I’ve interviewed dozens of gunshot victims; immediate pain is rarely reported. Often, the victim doesn’t realize he has been shot.

I know of someone who had a finger almost completly severed from his hand by a rifle bullet. He reported feeling nothing other than the sensation of an impact. Compare that with what happens if you strike a finger with a hammer while nailing — that causes immediate, intense pain.

People with severe injuries in car crashes most often do not feel great pain (at the time). But someone who’s finger got slammed in a car door will feel immediate pain.

This is simply an anecdote but i clearly remember an injury as a child with much the same effect. I broke an arm in five places. I had to run home a considerable distance cradling the arm but was stunned that i managed to navagate home in no pain with an arm that was severely misshapen. The pain did assuredly come later but i would guess that was after 10-15 minutes.

@Dent: I’ve been biopsied for a brain tumor. It means doctors put 5 needles into my brain I felt absolutly nothing. As doctors explained me before the surgery and as unbelievable as it may seem the brain was the only organ that is not innervated (exept the dura-mater).

I broke my finger when I was young. What ended up happening was a metal wire pulled the bone at the joint and yanked it out of my finger. I remember seeing it, there was so much blood, and yet I cant remember the pain. The body has ways of dealing with traumatic injury, in part to help with survival.

There are also many cases in which the gunshot victim is conscious and talking immediately after the bullet strike — even when the injury later causes death.

Perhaps it’s apocryphal, but I’ve heard a story about a woman who shot an home intruder multiple times with a pistol, and according to autopsy results the bullet wounds were severe enough to cause unconsciousness within 60 seconds and death within 120 seconds. Unfortunately for the woman, in the 60 seconds that elapsed before the intruder lost consciousness, he beat her to death with his bare hands.

Survivor here, eighteen years ago actually. Two shot gun slugs one lodged next to the spine and the other hit the skull and recessed back into the brain, both were fully penetrating through the brain. There are great success stories, I went to nursing school there after and now work in inpatient psychiatric medicine and speak to struggling TBI survivors. I’m honored to be a survivor and enjoy helping others.

On January 18 of this year my 28 year old nephew sat down on his sofa, placed his .40 cal pistol to his right temple and pulled the trigger. He was still breathing, heart beating and even vomiting, before and after the police then Paramitics arrived. He was pronounced brain dead upon arrival to the ER. But lived for five days after. 5 long hours after the ventilator was removed. The bullet he used was a full metal jacketed .40 S&W. The strangest and to our family, Most heart wrenching thing, and I hope someone on here can help us to understand this.. After shooting himself he had the presence of mind to lay the gun down on the coffee table which was about 2 feet from where he was laying when we found him. I’d have thought that the ballistic shock would have knocked him out. I feel as Does my family horrible thinking that he may have realized what he attempted and thought briefly, maybe that it was a terrible mistake. We fear he suffered emotionally. It seems so unusual to all of us. However the bullet did not expand but passed straight through and made a perfectly oval hole in the ceiling no larger than the bullet itself, on that trajectory. If anyone can explain this please do.

December 10th, 2014 I shot myself in the head with a .45 handgun. The bullet went through my motor cortex, bounced off my skull and exited my occipital lobe. I was in my car being pulled over by a cop when I pulled the trigger, which I mention to explain the prompt arrival of the paramedics. I retained consciousness, but it was in and out. I remember everything the EMTs were saying, what I could smell taste and my ears ringing. I did not feel any pain. With gunshots to the brain, my neuro surgeon explained sometimes your brain is so overwhelmed with the damage it cannot process pain. Part of my skull was removed, and fragments of bone and shrapnel were removed that would not do more damage by removing them. The result was total paralysis in my legs and left arm. So yes, the result is completely dependent on the area affected. Since it was my motor cortex primarily, it was my motor skills. I was 18, though, which means I had more neuro plasticity and a greater chance for a full recovery. A year later I walk with a cane and my arm is functional. So I have learned the result is dependent on the area traumatized and age.

Also a survivor from a gunshot to the forehead. This was not self-inflicted. I got shot by a .22 rifle during a traffic stop. He was about 20 feet away and shot through my squad’s windshield. The slug embedded in my forehead about an inch above my right eye and came to rest about one-eighth on an inch from penetration; about as close as it gets. The pain was minimal. I’ve always described it as feeling like getting snapped by a rubber band. It’s been about two-and-a-half years now and I have pretty regular and intense headaches that have mostly to do with a severed sinus duct where the slug landed. And unfortunately, I have quite a few sleepless nights. I am thankful everyday for being alive and mostly well, especially in comparison to others in this exclusive club.